Concussion underdiagnosis

K. Myers, N. Kondamudi, C. Hartsgrove and A. Weingart.  Making the Diagnosis of Concussion in the Emergency Department: Are We Hitting the Mark?  Annals of Emergency Medicine, 2017-10-01, Volume 70, Issue 4, Page S87.

Study Objectives

There has been increased interest in concussion among the scientific and lay press in the last 20 years, and the emergency department (ED) is where patients commonly seek medical evaluation after a head injury. The diagnosis of concussion can be easily missed because it is a clinical diagnosis, often made after ruling out more serious injuries. The objective of this study is to determine the prevalence of concussion among children seen at our ED (17k annual visits in 2015) and determine the extent of underdiagnosis.

Methods

This study was conducted as a retrospective chart review of children presenting with head injury to the emergency department in July-December 2013 and in January-December 2015. Data collected included age, sex, time of presentation, time since injury, injury mechanism, clinical features, imaging data and diagnosis. Patients that met criteria for the diagnosis of concussion, but not given concussion as a discharge diagnosis were considered to have underdiagnosis. Secondary analysis was performed to determine characteristics of patients with concussion, and any differences in the rate of diagnosis between 2013 and 2015.

Results

Of the 610 patient evaluated for head injury (2013: 221, 2015: 389), 238 (39%) had features compatible with the diagnosis of concussion (2013: 100, 45%, 2015: 138, 35.5%). Diagnosis of concussion was documented in 89 patients (2013: 35, 2015: 54), for overall underdiagnosis rate of 62.6% (2013: 65%, 2015: 61%). The majority of patients were boys (67%), and the mean age was 11 years (SD 5.3). There was no difference in these demographics between 2013 and 2015. CT scan of the head was performed in 167 patients (2013: 69, 2015: 98), resulting in an overall head CT scan rate of 70% (2013: 69%, 2015: 71%). Among the 2015 data, the most common mechanism of injury was falls (23%) followed by assaults (15.9%) and motor vehicle accidents (15.2%).

Conclusions

The prevalence of concussion in this study is just under 1% of all pediatric ED visits and 39% among patients presenting to the ED with head injury. Underdiagnosis occurred in 63% of patients with signs and symptoms compatible with this diagnosis. As it is a clinical diagnosis, lack of provider recognition of the constellation of signs and symptoms that satisfy the diagnostic criteria may have contributed to such a large underdiagnosis rate. It is important to make the specific diagnosis of concussion for parent and school understanding, and to facilitate appropriate treatment, discharge instructions, and follow-up.

Courtesy of:  https://www.medpagetoday.com/meetingcoverage/acep/68955